BILL ANALYSIS                                                                                                                                                                                                    Ó

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        SB 233 (Pavley)
        As Amended July 14, 2011
        Majority vote

         SENATE VOTE  :37-0  
         HEALTH              17-0        APPROPRIATIONS      17-0        
        |Ayes:|Monning, Logue, Ammiano,  |Ayes:|Fuentes, Harkey,          |
        |     |Atkins, Bonilla, Eng,     |     |Blumenfield, Bradford,    |
        |     |Garrick, Gordon, Hayashi, |     |Charles Calderon, Campos, |
        |     |Bonnie Lowenthal,         |     |Davis, Donnelly, Gatto,   |
        |     |Mansoor, Mitchell,        |     |Hall, Hill, Lara,         |
        |     |Nestande, Pan,            |     |Mitchell, Nielsen, Norby, |
        |     |V. Manuel Pérez, Silva,   |     |Solorio, Wagner           |
        |     |Williams                  |     |                          |
        |     |                          |     |                          |
         SUMMARY  :  Clarifies existing law to explicitly permit appropriate 
        licensed personnel to perform consultations and treatment in an 
        emergency department (ED) if within their existing scope of 
        practice.  Specifically,  this bill  :   

        1)Revises the existing definition of "emergency services and care" 
          to mean medical screening, examination, and evaluation by a 
          physician or surgeon, or, to the extent permitted by applicable 
          law, other appropriate licensed personnel acting within their 
          scope of licensure under the supervision of a physician and 
          surgeon, to determine if an emergency medical condition or active 
          labor exists.

        2)Clarifies that, upon a determination that an emergency medical 
          condition or active labor exists, "emergency services and care" 
          also includes the care, treatment, and surgery, if within the 
          scope of the appropriate licensed personnel's license, necessary 
          to relieve or eliminate the emergency medical condition, within 
          the capability of the facility. 

        3)Includes the rendering of a decision regarding hospitalization or 
          transfer by telephone or other means of communication in the 
          existing definition of "consultation" and authorizes other 
          appropriate licensed personnel acting within their scope of 


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          licensure to provide consultation.

        4)Requires the request for consultation to be made by the treating 
          physician and surgeon, or by other appropriate licensed personnel 
          acting within their scope of licensure, provided that it is made 
          with the contemporaneous approval of the treating physician and 

        5)Permits the treating physician and surgeon to request to 
          communicate directly with the consulting physician and surgeon, 
          and requires, when determined to be medically necessary, jointly 
          by the treating physician and surgeon and the consulting physician 
          and surgeon, the consulting physician and surgeon to examine and 
          treat the patient in person. 

        6)States that the consulting physician and surgeon is ultimately 
          responsible for providing the necessary consultation to the 
          patient, regardless of who makes the in-person appearance. 

        7)Authorizes, in addition to a physician or surgeon, other 
          appropriate licensed personnel acting within their scope of 
          licensure to determine when a patient's emergency condition has 
          been stabilized. 

        8)Prohibits this bill from being construed to expand the scope of 
          licensure for licensed personnel providing services in the ED.

         FISCAL EFFECT  :  According to the Assembly Appropriations Committee, 
        negligible direct state fiscal impact.  This bill clarifies state 
        law and conforms state law to existing federal law and current 
        practice, and is not likely to significantly change the delivery of 
        emergency medical care.  

         COMMENTS  :  According to the author, this bill is prompted by a 
        recent situation in which a physician was requested to provide a 
        consultation in the ED at Mission Hospital in Orange County and sent 
        his physician assistant (PA) to provide the further assessment.  The 
        PA was subsequently prohibited from providing the consultation.  The 
        author maintains that although these types of services are routinely 
        authorized by supervising physicians at hospitals, in this case, the 
        hospital pointed out that existing law does not explicitly authorize 
        a PA to perform consulting and treatment services in an ED setting.

        The author argues that state law is in conflict with federal law, 


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        which permits PAs to provide consults in the ED, and this bill would 
        make state law consistent with federal law.  The author adds that 
        PAs working in specialty practice areas provide an essential service 
        to the ED as they can expedite the admission or surgical preparation 
        of the patient under the supervision of the physician and surgeon, 
        and, in doing so, vacate a bed for an incoming ED patient.  The 
        author contends that as long as evaluation, consultation, and 
        treatment is performed pursuant to a PA's scope of practice, 
        delegation of services agreement, and under the supervision of a 
        physician and surgeon, this type of care by a PA is routine and 
        should not be unduly restricted by omissions and lack of clarity in 
        the current definition of emergency services and care in state law.

        The sponsor of this bill, the California Academy of Physician 
        Assistants (CAPA), states that existing law allows PAs to perform a 
        variety of medical services set forth in state regulations when 
        rendered under the supervision of a physician and surgeon.  CAPA 
        argues that this bill clarifies an inconsistency in state law by 
        explicitly authorizing PAs and other mid-level practitioners to 
        perform consultative and treatment services in the hospital ED, 
        thereby increasing the provision of urgent medical care and 
        decreasing patient overcrowding.  

        The California Nurses Association (CNA) objects to this bill and 
        views it as an expansion of scope of practice and an encroachment 
        into the practice of medicine.  CNA asserts that the law is clear 
        that physicians may provide emergency consults, care, treatment, and 
        surgery; and, allowing "other appropriate personnel" to provide 
        these services raises concerns over whether or not any of these 
        types of personnel retain the appropriate levels of training and 
        competence to perform these services.  CNA believes this bill 
        lessens standards of care for patients by promoting the broad 
        delegation of certain aspects of care, including consultations and 
        stabilization determinations, to non-physician practitioners. 

        The California Chapter of the American College of Emergency 
        Physicians opposes this bill unless it is amended to clarify that 
        the definitions of emergency services, care, and consultation 
        include delivery by appropriate licensed personnel to the extent 
        permitted by hospital by-laws or rules and regulations as provided 
        under federal law. 

         Analysis Prepared by  :    Cassie Royce / HEALTH / (916) 319-2097 


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